Peptic Ulcer Disease
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Introduction
Peptic ulcer disease is gastric and duodenal ulcers.
The most common causes include infection with the bacteria H. pylori and NSAIDs (non-steroidal anti-inflammatory drugs).
The Case of...
Causes and Risk Factors
H pylori infection is the most important risk factor and is associated with 50-95% of patients with gastro-duodenal ulcers. Chronic NSAID is the second-most common, and people who take them have a prevalence of 10-25% of ulcers - 5-10x the expected rate. Other medications include
- bisphosphonates
- potassium
- steroids (indirectly)
- chemotherapy drugs
Cigarette smoking causes 2x incidence, 2x as long to heal, 2x as likey to recur, but alcohol, diet, caffeine, or stress do not appear to cause ulcers.
Shock or physical stress can reduce blood flow to the mucosa and reduce mucus production, causing acid-mediated damage in the majority of severely ill people. Stress ulcers tend to be superficial, though occult blood loss is common.
Zollinger-Ellison syndrome is a gastrin-producing syndrome, potentially leading to severe ulcerations. Gastric cancer can also have an ulcerative appearance.
Pathophysiology
Mucous defense mechanisms include mucus, water, bicarbonate, phospholipids, and glycoproteins. This maintains a neutral pH and the epithelium.
Signs and Symptoms
- history
- physical exam
History
Abdominal pain is generally epigastric. It is usually a dull ache, but can be sharp or burning. less than 20% of people have a hunger-like pain. There is some correlation with food intake relieving duodenal ulcers and exascerbating pain associated with peptic ulcers, but this is not always useful. NSAID ulcers typically are painless.
Nausea and vomiting are typically associated with peptic ulcers. Weight loss is frequently reported.
Duodenal ulcers typically present with an epigastric gnawing pain, with onset 2-3 hours after meals. Pain can be relieved with meals or antacids. Nocturnal pain is more common.
Gastric ulcers have pain onset 30-60 min after eating, may not be relieved by food, do not often have nocturnal pain, and display weight loss in 50% of people.
Physical Exam
Due to overlap of clinical features with other conditions, physical exam is often not helpful.
Investigations
- lab investigations
- diagnostic imaging
Lab Investigations
H pylori testing is essential in all people with PUD.
This can be done by the urea breath test. Avoid antibiotics, PPIs, bismuth, and other antisecretory medications.
following biopsy through endoscopy.
Diagnostic Imaging
Barium contrast studies have 80% sensitivity, with bigger ulcers more likely to be picked up. Barium pools outside the lumen, and thickened folds radiate to the crater. No potential for biopsy exists.
If available, endoscopy is usually preferred because it allows tissue sampling and hemorrhage control, along with visualization.
Differential Diagnosis
These symptoms can mimic other diseases such as cholecystisits, pancreatitis, gastric cancer, and GERD. Myocardial ischemia or infarction, especially in the inferior wall, can resemble peptic ulcer.
Treatments
Lifestyle
Avoid smoking and alcohol, as well as excess NSAIDs.
Eradicating H pylori significantly reduces ulcer recurrence.
Proton pump inhibitors are the most effect drug, both for gastric and duodenal ulcers, but are also more expensive.
H2 blockers
H2 blocker, reducing the effect of histamine only.
ranitidine and cimetidine .
Proton Pump Inhobitors
more powerful reducer of acid; blocks the H/K antiporter.
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lansoprazxole
Consequences and Course
Peptic ulcers can cause result in asymptomatic iron deficiency anemia, abdominal pain, obstruction and dysphagia, perforation, or hemorrhage.
Hemorrhage is a common consequence.
Perforation can lead to perotoneal symptoms.
Strictures, even after ulcer healing, can cause obstruction in narrowed areas.
Additional Resources
Topic Development
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